Question 1

When recording physical findings, which data are recorded first for all systems?

Accepted Answer

A)  Review of systems
B)  Percussion
C)  Palpation
D)  Auscultation
E)  Inspection

Question 2

Which of the following is not a characteristic of the plan portion of the problem-oriented medical record?

Accepted Answer

A)  A plan is developed for each problem.
B)  Therapeutics
C)  Patient education
D)  Differential diagnosis
E)  Diagnostics ordered

Question 3

Subjective and symptomatic data are

Accepted Answer

A)  documented in your assessment.
B)  not mentioned in the legal chart.
C)  placed in the history sections.
D)  recorded with the examination technique.
E)  documented with the findings.

Question 4

Regarding another provider's documented work, it

Accepted Answer

A)  is not relevant in a legal proceeding.
B)  will not affect clinical decisions.
C)  may be copied verbatim into your documentation.
D)  must be attributed to the source if entered.
E)  does not affect patient care.

Question 5

Data relevant to the social history of older adults include information on

Accepted Answer

A)  family support systems.
B)  extra time to assume positions.
C)  over-the-counter medication intake.
D)  date of last cancer screening.
E)  previous health care visits.

Question 6

The patient's perceived disabilities and functional limitations are recorded in the

Accepted Answer

A)  problem list.
B)  general patient information.
C)  social history.
D)  review of systems.
E)  past medical history.

Question 7

Your patient returns for a blood pressure check 2 weeks after a visit during which you performed a complete history and physical examination. This visit would be documented by creating a(n)

Accepted Answer

A)  progress note.
B)  incident report.
C)  problem-oriented medical record.
D)  triage note.
E)  new problem list.

Question 8

What finding is unique to the documentation of a physical examination of an infant?

Accepted Answer

A)  Fontanel sizes
B)  Liver span
C)  Prostate size
D)  Thyroid position
E)  Visual acuity A

Question 9

Ms. S reports that she is concerned about her loss of appetite. During the history, you learn that her last child recently moved out of her house to go to college. Rather than infer the cause of Ms. S's loss of appetite, it would be better to

Accepted Answer

A)  defer or omit her comments.
B)  have her husband call you.
C)  quote her concerns verbatim.
D)  refer her for psychiatric treatment.
E)  record your interpretations. C

Question 10

The position on a clock, topographic notations, and anatomic landmarks

Accepted Answer

A)  are methods for recording locations of findings.
B)  are used for noting disease progression.
C)  are ways for recording laboratory study results.
D)  are usually misinterpreted.
E)  should not be used in the legal record.

Question 11

Drawing of stick figures is most useful to

Accepted Answer

A)  compare findings in the extremities.
B)  demonstrate radiation of pain.
C)  indicate organ enlargement.
D)  indicate mobility of masses.
E)  indicate consistency of lymph nodes.

Question 12

The OLDCHARTS mnemonic is a way of documenting which of the following?

Accepted Answer

A)  History of present illness
B)  Past medical history
C)  Family history
D)  Social history
E)  Review of systems

Question 13

When recording assessments during the construction of the problem-oriented medical record, the examiner should

Accepted Answer

A)  combine all data into one assessment.
B)  create an assessment for each problem on the problem list.
C)  create an assessment for every abnormal physical finding.
D)  create an assessment for every symptom presented in the history.
E)  create an assessment for each abnormal laboratory finding.

Question 14

Ms. G is being seen for her routine physical examination. She is a college graduate and president of a research firm. Although her exact salary is unknown, she has adequate health insurance. Most of the above information is part of Ms. G's _____ history.

Accepted Answer

A)  identifying information
B)  past medical
C)  personal and social
D)  present problem
E)  family

Question 15

Which of the following is an example of a problem requiring recording on the patient's problem list?

Accepted Answer

A)  Common age variations
B)  Expected findings
C)  Findings of unknown origin
D)  Minor variations
E)  Only findings that have a clear etiology

Question 16

In which section of the newborn history would you find details of gestational assessment and extrauterine adjustment data?

Accepted Answer

A)  Family
B)  General patient information
C)  Personal and social
D)  Present problem
E)  Past medical

Question 17

The review of systems is a component of the

Accepted Answer

A)  physical examination.
B)  health history.
C)  assessment.
D)  past medical and surgical history.
E)  personal and social history.

Question 18

If information is purposefully omitted from the record, you should

Accepted Answer

A)  erase the notes that are not pertinent.
B)  never explain the emission.
C)  state in the record why the information was omitted.
D)  use correction fluid to omit the information.
E)  know that only helpful data are recorded.

Question 19

Information recorded about an infant differs from that of an adult, mainly because of the infant's

Accepted Answer

A)  attention span.
B)  developmental status.
C)  nutritional differences.
D)  source of information.
E)  limited past medical history. B

Question 20

A problem may be defined as anything that will require

Accepted Answer

A)  evaluation.
B)  medication.
C)  surgery.
D)  treatment.
E)  referral.

Exam 26: Recording Information

When recording physical findings, which data are recorded first for all systems?

Correct AnswerverifiedShow Answer

Which of the following is not a characteristic of the plan portion of the problem-oriented medical record?

Correct AnswerverifiedShow Answer

Subjective and symptomatic data are

Correct AnswerverifiedShow Answer

Regarding another provider's documented work, it

Correct AnswerverifiedShow Answer

Data relevant to the social history of older adults include information on

Correct AnswerverifiedShow Answer

The patient's perceived disabilities and functional limitations are recorded in the

Correct AnswerverifiedShow Answer

Your patient returns for a blood pressure check 2 weeks after a visit during which you performed a complete history and physical examination. This visit would be documented by creating a(n)

Correct AnswerverifiedShow Answer

What finding is unique to the documentation of a physical examination of an infant?

Correct AnswerverifiedA

Ms. S reports that she is concerned about her loss of appetite. During the history, you learn that her last child recently moved out of her house to go to college. Rather than infer the cause of Ms. S's loss of appetite, it would be better to

Correct AnswerverifiedC

The position on a clock, topographic notations, and anatomic landmarks

Correct AnswerverifiedShow Answer

Drawing of stick figures is most useful to

Correct AnswerverifiedShow Answer

The OLDCHARTS mnemonic is a way of documenting which of the following?

Correct AnswerverifiedShow Answer

When recording assessments during the construction of the problem-oriented medical record, the examiner should

Correct AnswerverifiedShow Answer

Ms. G is being seen for her routine physical examination. She is a college graduate and president of a research firm. Although her exact salary is unknown, she has adequate health insurance. Most of the above information is part of Ms. G's _____ history.

Correct AnswerverifiedShow Answer

Which of the following is an example of a problem requiring recording on the patient's problem list?

Correct AnswerverifiedShow Answer

In which section of the newborn history would you find details of gestational assessment and extrauterine adjustment data?

Correct AnswerverifiedShow Answer

The review of systems is a component of the

Correct AnswerverifiedShow Answer

If information is purposefully omitted from the record, you should

Correct AnswerverifiedShow Answer

Information recorded about an infant differs from that of an adult, mainly because of the infant's

Correct AnswerverifiedB

A problem may be defined as anything that will require

Correct AnswerverifiedShow Answer

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A

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C

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B

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